Cushing's Syndrome
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Transcript of Cushing's Syndrome
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Case presentationDone by: Dr. Rahma ShahBahai
Medical intern
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History…
36 y.o single Saudi female k/c of HTN, T2DM and dyslipidemia
Direct admission from OPD.
Presented with lower back pain, headache and inability to
walk for 3 months.
referred from KFH (Hafof) for persistent hypokalemia for
further investigation.
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HPI:
3 months Hx of progressive bilateral lower limbs weakness.
Start as a simple weakness>>can’t carry her weight during
standing>>become wheelchair bound.
Headache and lower back pain.
No Hx of sphincter incontinence.
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Drug Hx:
Aldactone 50 mg PO BID Nifedipine 40 mg PO OD Hydralazine 50 mg PO Q6H Atorvastatin 20 mg PO OD Labetalol 100 mg PO BID Diamicron 90 mg PO OD
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PH:
uncontrolled HTN >10 years
Dyslipidemia+T2DM ~3month
2ry Amenorrhea ~15 yrs.
Her menarche @ 13>> stopped
didn't seek medical advice.
No surgical Hx.
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FH:
father in good health.
Mother >>HTN
Sis1: HTN+DM
Sis 2: passed away (leukemia)
sis 3: weight gain+2ry amenorrhea
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Systemic review:
No mood changes
No dizziness
No blurred vision
excessive hair growth
acne
No respiratory or cardiac symptoms
No nausea, vomiting, diarrhea or constipation
No urinary symptoms
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D.Dx ???
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Examination…
General:
Obese, round face, comfortable in the bed, not in distress.
Vitals: T 37.7 ,p 90, RR 18, BP 160/100
Skin:
hirsutism, facial plethora, acne, dorsocervical fat deposition, supraclavicular fat deposition.
Chest: clear, good air entry bilateral.
CVS: S1,S2+0
Abdomen: distended, White striae ~0.5-0.7 cm, positive bowel sound.
CNS: conscious, alert
Extremities: bruises
U.L: power 4/5, reflexes normal
L.L: muscles wasting, bruises, no edema, power 3/5, reflexes normal
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Labs:
Cbc
Liver panel
Renal/lyte
Lipid profile
All within her base line, except for:
K 2.5
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Hospital course…
Pt. loss of her consciousness < 1min. Notice abnormal movement, not typical for convulsion K 2.4 ICU transferred. Observation, K-replacement, ECG
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Investigations???
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Labs:
Cortisol level am 313.6
Cortisol level pm 2017.8
ACTH 31
DST 331
FT4 13.5
FT3 2.44
T3H 0.09(SET)
E2 142
LH <0.07
FSH 0.09
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Brain CT:
cystic density 20*20 nm seen compressing the pituitary gland
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Brain MRI:
cystic mass lesion 2.5*1.7 cm with evidence of hemorrhagic is seen, optic chiasma is displaced cronaly
Finding consistent rathke cleft cyst complicated by hemorrhagic or cystic degeneration of pituitary macro-adenoma.
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Diagnosis is…..?ACTH-dependent Cushing’s syndrome
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Harvey Williams Cushing
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Cushing’s Syndrome= Hypercortisolism
Cushing's disease= Cushing's syndrome 2ry to pituitary ACTH
hypersecretion
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Etiologies:
Iatrogenic= exogenous glucocorticoid>>most
common
Cushing’s disease= endogenous 70%
Pituitary adenoma/hyperplasia
Adrenal tumor 25%
Ectopic ACTH 10%:
Carcinoid, SCLC, medullary thyroid cancer, pheo.
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Approach…
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TTT..
Mainly>>surgical resection
Medication
Replacement therapy lifelong.
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Thank you….